Hyperadrenergic Crisis

Abstract

The patient is a 40-year-old nurse who presented with a hypertensive crisis due to an unrecognized pheochromocytoma. The patient had no significant past medical history or family history and developed hypertension 2 years prior to her event at age 38. In the 6 months prior to her event, her blood pressure was more difficult to control. She also developed diabetes with highly variable glucose levels also difficult to control. She had had a 1-year history of headaches, diaphoresis, and palpitations. She presented to the emergency room after a witnessed collapse at home. Her initial blood pressure was 210/125, heart rate 135, and very short of breath. She was intubated and was difficult to ventilate. Her echocardiogram showed a moderately dilated left ventricle with an LVEF of 15 % and moderate to severe mitral regurgitation. She underwent cardiac catheterization that showed normal coronary arteries. She was transferred by helicopter to our institution to be placed on ECMO. At our institution she was treated with intravenous nicardipine, phenoxybenzamine, and metyrosine. A repeat cardiac echo showed an LVEF of 30 % and her blood pressure was 180/110. Imaging demonstrated 7 cm left adrenal mass. Laboratory testing showed a plasma epinephrine of >30,000 pg/ml (ULN 200) and plasma norepinephrine of 35,556 pg/ml (ULN 520). She remained intubated in the ICU during blood pressure control. On hospital day 6, she underwent an uneventful laparoscopic left adrenalectomy. Final pathology showed a relatively benign pheochromocytoma (PASS score of 4). She was extubated on postoperative day #1 and was discharged to home on postoperative day #3.

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